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From the New York City Department of Health and Mental Hygiene, New York, New York.
Acknowledgments: The authors thank Richard Selik, MD, Centers for Disease Control and Prevention HIV Incidence and Case Surveillance Branch, for careful review of the manuscript; the field surveillance and data support staff, especially Sonny Ly and Walter Smith, New York City DOHMH HIV Epidemiology Program, for assistance with case reviews and data management; and the New York City DOHMH Office of Vital Statistics for sharing data and expertise.
Grant Support: Through a cooperative agreement between the New York City DOHMH HIV Epidemiology Program and the Centers for Disease Control and Prevention (U62/CCU223595).
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Judith E. Sackoff, PhD, HIV Epidemiology Program, Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, 346 Broadway, Room 706, CN44, New York, NY 10013; e-mail, email@example.com.
Current Author Addresses: Drs. Sackoff and Torian, Mr. Hanna, and Ms. Pfeiffer: HIV Epidemiology Program, Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, 346 Broadway, Room 706, CN44, New York, NY 10013.
Author Contributions: Conception and design: J.E. Sackoff, D.B. Hanna, M.R. Pfeiffer, L.V. Torian.
Analysis and interpretation of the data: J.E. Sackoff, D.B. Hanna, M.R. Pfeiffer, L.V. Torian.
Drafting of the article: J.E. Sackoff, D.B. Hanna.
Critical revision of the article for important intellectual content: J.E. Sackoff, D.B. Hanna, M.R. Pfeiffer, L.V. Torian.
Final approval of the article: J.E. Sackoff, D.B. Hanna, M.R. Pfeiffer, L.V. Torian.
Statistical expertise: D.B. Hanna.
Obtaining of funding: J.E. Sackoff.
Administrative, technical, or logistic support: J.E. Sackoff, D.B. Hanna, M.R. Pfeiffer.
Collection and assembly of data: D.B. Hanna, M.R. Pfeiffer.
Between 1999 and 2004 in New York City, the mortality rate for both HIV-related and non–HIV-related causes among persons with AIDS decreased, continuing a trend that began with the introduction of HAART. Although HIV-related causes accounted for most deaths, the proportion of deaths due to non–HIV-related causes increased by 33% and accounted for approximately one fourth of all deaths of persons with AIDS during this period. More than three quarters of non–HIV-related deaths were due to substance abuse, cardiovascular disease, and cancer. In recognition of these trends, the IDSA has stressed the importance of managing persons who are living with AIDS according to standard practices appropriate for their age and sex, regardless of HIV status (13). Our analysis suggests that this should include helping patients change behaviors, such as smoking; screening for early detection of cancer; and monitoring chronic conditions, such as diabetes and hypertension. An aging population will also present new treatment challenges, such as the interaction between medications for chronic comorbid conditions and HAART (40).
The HIV-related mortality rate decreased by 54.9% overall, with an average annual decrease of 49.6 deaths per 10 000 persons with AIDS (P < 0.001), while the non–HIV-related mortality rate decreased by 34.3%, or 7.5 deaths per 10 000 persons with AIDS annually (P = 0.004). Mortality rates did not decrease significantly over time for the 3 leading non–HIV-related underlying causes of death (cardiovascular-, cancer-, and substance-related deaths) (P > 0.100).
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We read with interest the recent article by Sackoff and colleagues on causes of death among persons with AIDS in the HAART era in New York City (1). This is a comprehensive analysis of non-HIV causes of death and may be representative of patterns in the United States as a whole. The authors conclude that the proportion of deaths due to non-HIV-related causes increased by 33% between 1999 and 2004 and they suggest that these findings require a shift in the provision of health care for persons with AIDS from a focus on HIV infection to a model that encompasses other aspects of physical and mental health.
This shift in causes of death represents a major triumph of medical care in the United States, but the authors' analysis exposes another significant health problem in persons with HIV infection, namely death due to hepatitis and liver disease. Although liver disease is not included specifically in the authors' top ten list of non-HIV causes of death, when the individual categories of hepatitis C, liver cancer and cirrhosis of the liver are combined, they account for the third largest category after complications of drug abuse and dependency and chronic ischemic heart disease. In addition, the contributions of alcohol abuse/ dependence and drug abuse/ dependence to liver disease are not accounted for and may increase this category substantially.
It is estimated that 30% of HIV-infected individuals in the United States are co-infected with the hepatitis C virus (HCV) and a further 5- 10% with the hepatitis B virus (HBV) (2,3,4). These chronic viral infections, together with alcohol abuse and diabetes, are major contributors to cirrhosis and liver cancer. Although current treatments for alcoholic liver disease and non-alcoholic steatohepatitis remain inadequate, considerable progress has been made towards developing effective therapies for chronic hepatitis B and hepatitis C and these therapies have the potential to reduce the rates of death and liver cancer. Further studies are needed to ascertain whether treatment of hepatitis C and hepatitis B viral will also reduce the mortality rate from liver disease in HIV positive persons. In summary, we feel it is important to recognize the significant contribution of hepatitis and liver disease to morbidity and mortality associated with HIV infection and AIDS. Clearly, considerable further research is needed into causes and treatment of chronic liver disease in persons with AIDS, and liver disease should be specifically addressed in future models of health care provision for persons infected with HIV.
Causes of Death in People with AIDS in New York City between 1999 and 2004
The summary below is from the full report titled “Causes of Death among Persons with AIDS in the Era of Highly Active Antiretroviral Therapy: New York City.” It is in the 19 September 2006 issue of Annals of Internal Medicine (volume 145, pages 397-406). The authors are J.E. Sackoff, D.B. Hanna, M.R. Pfeiffer, and L.V. Torian.
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